Who Wants to Save a Junkie?

Dr. Gary Oxman spent his career trying to save people who don't care whether they live or die.

Oxman—who just retired as health officer for Multnomah, Clackamas and Washington counties—has long wanted to do more to rescue drug users.

He was one of the earliest supporters in Portland of free needle exchanges, aimed at stopping the spread of HIV among addicts who share syringes. That idea, first floated in the late 1980s, was often met with derision: Why should we condone the use of dangerous drugs by making it safer for addicts to keep shooting up?

Oxman helped champion a needle-exchange program in Portland, and he says it's the reason the city never saw the explosion of HIV among drug users as other communities did.

"Pure and simple," Oxman says. "Something that went very right."

But Oxman, who retired last month, has been unable to reverse another epidemic: opiate addiction.

In Oregon, unintentional drug overdoses now kill more people than car accidents. The drugs that are driving up those numbers and killing most often are opiates—heroin and prescription pain medication, including methadone. In 2011, Oregon saw nearly 300 people die because of opiate overdoses—the highest year yet for heroin deaths. The rate of people dying from opiate-related overdoses has more than tripled in the past decade.

In fact, Oregon has the highest rate of opiate abuse among people under 25 than anywhere else in the country.

More than half the drug overdose deaths in Oregon are linked to prescription opiates such as OxyContin and Vicodin.

In Multnomah County, the top killer is heroin. Nearly half of drug users addicted to heroin here say they got hooked first by taking prescription pain pills.

Gov. John Kitzhaber has called the state's addiction to these drugs "calamitous."

Oregon has tried to battle drug addiction with education and treatment programs.

But Oxman wants the state to go further.

He wants to expand the use of another drug that will snap users out of an overdose of heroin, methadone or pain pills.

It's commonly called Narcan, and for more than four decades paramedics and emergency-room personnel have injected it into people dying of opiate overdoses to give them a chance to hang on. 

Across the country, recovery agencies and treatment centers have been making Narcan (also known by its generic name, naloxone) available to drug users' friends, families, counselors and even addicts themselves—giving them a chance to deliver a life-saving dose before paramedics arrive. 

Considered radical when it started, the wider use of Narcan has saved as many as 10,000 lives by reversing the effect of overdoses.

But Oregon—once in the forefront of helping protect the health of drug addicts—has not joined in.

Now, Oregon senators are considering a bill to make it easier to distribute Narcan. By doing so, lawmakers will shift the state's efforts to fight drug overdoses not just with education, prevention and treatment, but by giving addicts a safety net even as they practice self-destructive behavior. 

"These overdoses are individual and community tragedies," Oxman says. "They can be treated, and so we don't need to have people dying needlessly."

A native of Minneapolis, Oxman came to Oregon after graduating from the University of Minnesota Medical School in 1978. When he was in private practice in the early 1980s, he recalls seeing patients he suspected were describing problems with pain that didn't exist.

"They were trying to manipulate me into giving them opiates," Oxman, 60, says. "That's always been there in the community. It's just way worse now than it was a few decades ago."

Oxman was named Multnomah County medical director in 1984, and the county's public health officer three years later. Around 2000, Oxman helped reverse the spike in heroin deaths, in part by targeting addicts themselves with information about how to use the drug more safely.

The overdoses the Portland area sees now are not driven by heroin alone. The long line of drug deaths often begin at the prescription pads of doctors.

Nearly half of the prescriptions tracked by state officials last year were for opiates. That amounted to 3.7 million painkiller prescriptions—nearly one for every resident of Oregon.

Drug users say painkillers lead to addiction—43 percent of heroin users in Multnomah County say they were first hooked on prescription painkillers. (Heroin is often cheaper and easier to get than prescription drugs.) 

These drugs have created a widespread occasion of death. More than 60 percent of current opiate abusers say they've seen someone overdose in the past year.

"The docs are sort of trapped in this situation where patients are in pain and there's no logical alternative," Oxman says. "It's not bad doctors. It's the structure of the health-care system that's really driving this."

Tom Burns, director of pharmacy programs for the Oregon Health Authority, says in many cases physicians and dentists overprescribe pain meds to avoid having to write repeat prescriptions.

But Burns says the state has no intention of challenging physicians' autonomy when it comes to making medical decisions. "We're not Big Brother," Burns says.

Instead, the state has tried educating doctors. In 2009, the Oregon Legislature created the Oregon Prescription Drug Monitoring Program, intended to help physicians track their patients' prescriptions, no matter who writes them. A medical professional who's concerned about a patient's use of OxyContin, for example, can log on and see if the patient has been "doctor shopping" by getting prescriptions from other sources.

Ryan Lufkin is a deputy district attorney in Multnomah County who focuses primarily on drug crimes—he estimates he's handled 1,100 drug cases in the last three years. He says too little money spent on recovery and treatment programs makes matters worse.

"The solution that seems to be the gold standard from a criminal-justice perspective is a treatment bed straight from a jail bed," Lufkin says. "The ultimate goal is not conviction, but treatment."

Last fall, Vero Majano came to Portland to help organize a film festival at the national convention of the Harm Reduction Coalition, an organization that works to help protect the health—and the rights—of people who use drugs.

Majano manages a drop-in center for the homeless in the Mission District of San Francisco. A social activist for years, Majano says most people don't understand the goal of harm reduction—in part because they demonize the drug-using community.

"There's this thing around drug use being evil," she says. "So the idea is that drug users are also bad. If people were to look at trauma, how people self-medicate—people use [drugs] for good reasons."

Majano's views reflected the message at the conference, which drew hundreds from around the country: Drug users should have no fewer rights to have their health and welfare protected than anyone else.

Yet proponents say society should do more than simply jail people who use drugs, or try to combat addiction through education and treatment programs. It also means helping keep addicts alive and healthy, even when they show no signs of stopping their drug use.

Take the case of Jake Rhew.

“He had a good heart—a compassionate soul,” Rhew’s stepmother, Kathy Thomes-Rhew, says.  

Before he was out of high school, Rhew got hooked on pain pills and stole medication from his family.

Rhew earned a GED diploma and enlisted in the Army National Guard, only to get kicked out. He moved to his father's house in Troutdale, stole to buy drugs, and tried to hide track marks on his arms. From 2009 to 2011, Rhew was arrested and charged five times for theft and once for possessing heroin. 

"Jake was desperate," Thomes-Rhew says. "It wasn't the Jake we knew, and that's what heroin can do to a person."

Rhew often recorded his battle with drugs on his Facebook page. "5 months sober," he wrote in June 2010. Two weeks before his last overdose, he wrote, "Damn going to sleep is a lot harder then [sic] passing out." And three days before he died, he posted a photo of himself: short-cropped blond hair, broad nose, clean white T-shirt, cautious smile. "Lookin' good Jake," a friend wrote.

On Aug. 23, 2011, Rhew, 29, was living at the men's residence center run by Volunteers of America in Northeast Portland when he and another client slipped into a bathroom to shoot heroin. Rhew was already in full nod by the time the center's staff found him. 

They couldn't revive him and he choked on his vomit. It's the center's only death.

"The counselors did everything that could be done," Thomes-Rhew says, but the staff didn't have access to Narcan. "At least he would have had a chance."

Greg Meenahan, director of development and communications for Volunteers of America, said medical privacy rules prevented him from talking about Rhew's death. But he says he would want Narcan in the hands of the organization's staff.

"We view this as a life-saving medication," Meenahan says. "If we were able to have it, there's little doubt that we would use it."

Narcan is a brand name for naloxone, developed in New York in 1960 by researchers who found the drug had a remarkable ability to block the effects of heroin and other opiates. 

The use of Narcan isn't quite as dramatic as perhaps the most famous scene of reviving someone in the throes of a drug overdose: the stabbing of Uma Thurman's character in the heart with an adrenalin-filled hypodermic needle in Quentin Tarantino's Pulp Fiction. 

The drug is often injected into the skin or a muscle, such as the biceps or thigh, and also comes as a nasal spray. Narcan throws the overdose into reverse—people can go from being blue and not breathing, to gasping for air in an instant withdrawal. 

John Sanborn knows how it feels.

He says he's been "Narcanned" by paramedics during heroin overdoses. Like the time he cooked up shot after shot in a Portland State University restroom. Or the time other junkies dragged him into a downtown apartment hallway and left him for dead. 

"It's horrible if you're living with an addiction," Sanborn says of Narcan's effects. "It brings you right down to where you were before you started shooting."

Narcan, Sanborn says, gave him a new chance at recovery. He's currently in Central City Concern's Community Engagement Program and is reconnecting with his 9-year-old son. "I realized that if I ever wanted to have any kind of a life," he says, "I was going to have to stop using drugs."

Sanborn got Narcan the way almost everyone in Oregon does: from a medical professional. But nearly 20 years ago, activists in other states realized the greater potential of the drug to save lives.

Dan Bigg, executive director of Chicago Recovery Alliance, says his organization had already seen harm-reduction strategies work with needle exchanges, slowing the AIDS epidemic among IV drug users. 

"[We] turn to the next big issue, which is overdose," Bigg says. "Why not use the existing pathways to get [Narcan] into the hands of people who overdose?"

In 1996, Bigg's organization began to train and distribute naloxone to laypeople. He says he has administered naloxone to an overdosing person at least six times. 

In 2010, Illinois finally made it legal to do what Bigg's group had been practicing, but he says he's frustrated that other parts of the country are behind.

"It's a pure antidote," Bigg says, "and you'd think it'd be available to scores of people suffering from premature death."

By that time, according to the Centers for Disease Control and Prevention, the use of Narcan by nonmedical professionals had broadened: Nearly 200 programs in 15 states and the District of Columbia were making Narcan more available. A 2012 CDC report said these programs helped reverse the effects of drug overdoses in more than 10,000 cases.

The CDC also found "many states with high drug-overdose death rates have no opioid-overdose prevention programs that distribute naloxone." That includes Oregon.

Allan Clear, executive director of the Harm Reduction Coalition in New York, says Narcan should be ubiquitous, especially in a city like Portland that has an opiate-overdose problem and has been a leader in needle exchanges.

"Overall, nationally, it's not that well-known as a community intervention program," Clear says. "In New York City and San Francisco—when the health department got on board—it really added that level of legitimacy to it. There's always been this level of caution because naloxone is one of those drugs you prescribe to use on someone else."

Dr. Sharon Stancliff, medical director of the Harm Reduction Coalition, says Narcan hasn't proved controversial in many communities.

"In New York, we actually have it set up so different kinds of agencies can distribute it to whoever they want," she says. "It has gone from being this sort of edgy thing to really becoming mainstream."

Dr. Sandro Galea, chairman of the epidemiology department at Columbia University, says Narcan was controversial in New York because people believed making it widely available would encourage drug users to indulge in opiates.

Galea's studies showed that drug users were not encouraged to be more reckless with heroin by having Narcan handy.

"There is no excuse for not making naloxone widely available to the [drug-using] community," Galea says.

If drug-overdose deaths are so common here, why is Oregon so far behind in the movement toward Narcan?

Oxman says cities and states that moved ahead with making Narcan more available also have more vocal and organized groups advocating for the welfare of drug users.

"I think when you get a critical mass of folks who believe in a particular issue, that makes organized action easier," Oxman says. "It's not that Portland lacks the drug users—we have lots and lots of drug users.

"Government is not in a position to be the leaders of harm reduction. It's really a community activity. And it is really bewildering why that hasn't been more prominent here."

In Portland, the organization that helped pioneer the needle-exchange program, Outside In, has been the obvious place to experiment with making Narcan more available.

Outside In works with homeless youth and what it calls "marginalized people." Kathy Oliver, Outside In's executive director, says health-care workers in the organization's clinic on Southwest 13th Avenue near Main Street are allowed to both inject and prescribe Narcan to people for use only on themselves.

Oliver would like to see Narcan more widely available. "The reason I want to do it is the same reason I wanted to open the syringe-exchange program," she says. "Death by overdose is preventable, so giving people the means to protect themselves makes sense."

But Outside In has been largely silent on the issue, despite the high overdose rates in Multnomah County. Oliver says she's aware that scores of other organizations like hers around the country have distributed Narcan or promoted its use.

"We did think the best way to achieve [a community pathway for naloxone] would be through the legislative and not through Outside In being a political advocate," she says.

In Salem, state Sen. Alan Bates (D-Medford) has introduced a bill to expand access to Narcan. Jackson County, where Bates lives, saw 30 people die in 2012 from opiate drug overdoses, according to Dr. Jim Shames, the county health officer.

Ashland, a community known for staging the Oregon Shakespeare Festival, was stunned recently by the death of three men within six weeks of each other—all from opiate overdoses. 

Maxwell Pinsky, 25, the son of a local blues musician, died Jan. 15 of a suspected opiate overdose; the Jackson County sheriff's office says the toxicology reports aren't finished yet. A month earlier, Ashland had two heroin-overdose deaths within a day of each other: Pinsky's friend Jordan Roth, 34, the son of a retired physician; and Colin McKean, 36, son of actor Michael McKean. 

Bates' bill would make Narcan a drug that anyone—from social workers to drug users—can get training to use and be able to purchase to have with them in the case of an emergency. Part of the bill also makes people who administer Narcan in an overdose situation immune from civil prosecution.

Emergency-room physicians have warned legislators the drug can cause a powerful reaction in people coming out of an overdose if the dosing isn't done properly.

"It's still a large question as to whether the public should have access to this powerful drug," says Jim Anderson, lobbyist for the Oregon Chapter of the American College of Emergency Physicians. "We have mixed emotions about it."

Oxman says passage of the bill will mark a big step in Oregon moving toward accepting the idea that government has a role to play in helping drug users stay alive, regardless of whether they stop using.

"I think people have really come around," he says, "to seeing what we're trying to do is help people who have problems with drug abuse, and there's a variety of different pathways to get there.” 

WWeek 2015